What are the treatment options for conjunctivitis?

Treatment Options for Conjunctivitis

The treatment of conjunctivitis must be tailored specifically to the underlying cause, with topical antibiotics indicated for bacterial conjunctivitis, antihistamines for allergic conjunctivitis, and supportive care for viral conjunctivitis. 1

Classification and Diagnosis

• Conjunctivitis should be classified as viral, bacterial, allergic, or related to other causes based on clinical presentation 2
• No single sign or symptom accurately differentiates viral from bacterial conjunctivitis, requiring careful assessment of symptoms and appearance 3
• Yellow crusting around the eyes is highly indicative of bacterial rather than viral or allergic etiology 4
• Mattering and adherence of eyelids on waking, lack of itching, and absence of history of conjunctivitis are strongly associated with bacterial conjunctivitis 5
• Itching is the most consistent sign in allergic conjunctivitis 5

Treatment by Type

Viral Conjunctivitis

• Supportive care is the mainstay of treatment, including artificial tears, cold compresses, and antihistamine eye drops 3
• Patients should be instructed to return if symptoms persist beyond 2-3 weeks 2
• Topical corticosteroids should be avoided as they can potentially prolong adenoviral infections and worsen HSV infections 2
• Strict personal hygiene with frequent handwashing is essential to decrease transmission risk 3

Bacterial Conjunctivitis

• Mild bacterial conjunctivitis is usually self-limited and resolves spontaneously without specific treatment in immunocompetent adults 2
• For moderate to severe cases, a 5-7 day course of broad-spectrum topical antibiotics is recommended 2
• Moxifloxacin 0.5% ophthalmic solution three times daily for 7 days is an effective first-line treatment 4, 6
• Clinical cure rates with moxifloxacin range from 66% to 69%, with microbiological eradication rates of 84% to 94% 6
• Cleaning eyelids and lashes with warm water and gentle soap to remove crusts before applying medication is essential 4
• Patients should be advised to return for evaluation if no improvement is seen after 3-4 days of treatment 2

Gonococcal and Chlamydial Conjunctivitis

• Systemic antibiotic therapy is required for gonococcal conjunctivitis, not just topical treatment 2
• Patients with gonococcal conjunctivitis require daily follow-up until resolution 1
• Chlamydial conjunctivitis necessitates systemic antibiotic therapy, as more than 50% of infants may have infection at other sites 1
• Sexual contacts should be treated concurrently 1, 2
• In low-to-middle income countries with limited antibiotic access, povidone-iodine 1.25% ophthalmic solution can be used for chlamydial conjunctivitis 1

Herpes Simplex Virus (HSV) Conjunctivitis

• Treatment options include ganciclovir 0.15% gel three to five times per day or trifluridine 1% solution five to eight times per day 2, 7
• Oral treatments include acyclovir, valacyclovir, or famciclovir 2
• Topical corticosteroids should be avoided as they potentiate HSV infection 2
• Follow-up within 1 week of treatment is recommended 2

Allergic Conjunctivitis

• Simple measures include wearing sunglasses as barriers to airborne allergens, cold compresses, and refrigerated artificial tears 1, 2
• Topical antihistamines with mast cell-stabilizing properties are the treatment of choice 1, 3
• For persistent or recurrent cases, mast cell stabilizers are recommended 1, 2
• In severe cases not adequately controlled, a brief course (1-2 weeks) of topical corticosteroids with a low side-effect profile may be added 1, 2

Special Considerations

• Hospitalization may be necessary for severe gonococcal conjunctivitis and is mandatory for neonatal conjunctivitis 2
• Patients treated with topical corticosteroids should be monitored for IOP elevation and cataract formation 2
• Contact lens wearers with conjunctivitis should suspend lens use until complete resolution 1
• Indiscriminate use of topical antibiotics or corticosteroids should be avoided 1, 2

Referral to Ophthalmologist

• Immediate referral is indicated for patients with:
  • Visual loss 2
  • Moderate or severe pain 2
  • Severe purulent discharge 2
  • Corneal involvement 2
  • Conjunctival scarring 2
  • Lack of response to therapy 2
  • Recurrent episodes 2
  • History of HSV eye disease 2
  • History of immunocompromise 2
  • Neonatal conjunctivitis 3

Common Pitfalls

• Failing to identify the specific type of conjunctivitis before initiating treatment 2
• Using topical corticosteroids in undiagnosed red eye, which can worsen HSV infections 2, 7
• Chronic use of vasoconstrictor agents can cause rebound vasodilation 2
• Oral antihistamines may induce or worsen dry eye syndrome 2
• Not considering sexual abuse in children with gonococcal or chlamydial infections 2
• Failure to identify and treat sexual contacts in cases of sexually transmitted conjunctivitis 2